Medication Administration/Delegated Nursing Skills Checklist

Medication Administration/Delegated Nursing Skills Checklist

Provider #7600117
Employee Name
Work Location
Siffrin Office Location

Skill

Rows	Oral Meds	Eye Meds	Ear Meds	Nose Drops/ Spray	Topical Meds	Inhalers	Nebulizer	Rectal Meds	Vaginal Meds
Date
Initials

Vital Signs

Rows	Blood Pressure	Temperature	Pulse	Respirations
Date
Initials

Skill

Rows	Clean Dressing Change	Bodily Intake and Output	Oral Suctioning	Urinary Catheter Care (External Only)	Emptying Collection Bag	Emptying and Replacing Colostomy Bag	Clean Catch Urine (Non-invasive)
Date
Initials

********************************************************************************************* Nurse Skills Check only (Check only as needed per home)

Skill

Rows	Glucometer (okay for MSL to complete)	Insulin Injection-filing the syringe	Insulin Injection- giving insulin	Insulin Injection- per insulin pen
Date
Initials

Emergency Medications

Rows	Diastat	EpiPen (okay for MSL to complete)	Glucagon
Date
Initials

Tube Feedings

Rows	G Tube	PEG Tube
Date
Initials

Certified staff are NOT permitted to administer the following:

1) Medications through a Nasogastric (NG) Tube

2) Parenteral or Intramuscular Injections

3) Intravenous (IV) Medications

4) Any Debriding Agent
Supervisor Name
Supervisor Signature
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit year
Nurse Name
Nurse Signature
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit year
Should be Empty: